Medicare Risk Adjustment Coder

BlueCross BlueShield of South Carolina

1d•Remote

About The Position

We are currently hiring for a Medicare Risk Adjustment Coder to join BlueCross BlueShield of South Carolina. In this role as a Medicare Risk Adjustment Coder, you will monitor and collect Medicare Stars data to improve health plan ratings, conduct specific medical record reviews, analyze findings, make recommendations for corrective actions, prepare formal documentation for compliance with applicable standards/regulations, and perform Health Plan Employer Data Information Set data collection (HEDIS), and National Committee for Quality Assurance (NCQA) accreditation activities. Description Location This position is full-time (40 hours/week) Monday-Friday with an 8-hour shift between 7:00am-9:00pm and will be fully remote. The candidate may be required to come on-site for occasional trainings, meetings, or other business needs.

Requirements

Bachelor's in a job-related field Degree Equivalency: 4 years job related work experience or Associate's and 2 years job related work experience
Professional certification in nursing, pharmacy, medical assistant, other healthcare training. OR – Certified professional in Healthcare Quality (CPHQ) certificate, Academy for Health Care Management (AHM) certificate, Health Information Management (HIM) certificate, Certified Risk Adjustment Coder (CRC) certificate or other related certification.
Minimum 2 years of managed care, quality improvement, medical research or clinical experience.
Minimum 2 year working with HEDIS standards, quality measures, and Medicare Advantage (can be concurrent).
Must be familiar with clinical terminology, and reading paper/electronic medical records.
Ability to work independently with a detailed focus on paper/electronic medical information and other sources to extract needed data for Medicare Star ratings.
Ability to understand and follow HEDIS NCQA, HOS, CAHPS, Pharmacy and Star measure data requirements.
Must maintain HIPPA compliance and quality standards.
Excellent verbal and written communication, customer service, organizational, presentation, problem solving, and analytical or critical thinking skills.
Proficient spelling, grammar, punctuation, and basic business math.
Ability to handle confidential or sensitive information with discretion.
Demonstrated ability to identify the need for and implement corrective actions.
Strong understanding of managed care.

Nice To Haves

Master's degree in healthcare or business-related field or bachelor’s degree and four years of related work experience.
Experience with Medicare Stars, HEDIS, Pharmacy data, NCQA, CAHPS, HOS, Medicare Stars methodology, risk adjustment, medical records and data analysis.
Experience with Retrospective chart review, Prospective gap validation (preferred), and RADV audits or audit preparation (highly preferred)
Minimum 4+ years of managed care, quality improvement, medical research or clinical experience.
Minimum 3+ years working with HEDIS standards, quality measures, and Medicare Advantage (can be concurrent).
Strong understanding of HCC and RxHCC models, Medicare Advantage risk adjustment methodology, and encounter data and claims submission processes (e.g., EDPS familiarity preferred)
Ability to persuade, negotiate, or to influence others.
Knowledge of mathematical or statistical concepts.
CPC, CRC, CCS, or equivalent
Prefer experience with data/analytic platforms such as hybrid tools, HEDIS engines, supplemental data sources, electronic medical records, Tableau, Microsoft Access, and Microsoft Excel.

Responsibilities

Coordinates HEDIS and Star measure data collection using analytic resources, paper records, electronic medical charts and other authorized resources.
Conducts data entry and review of Star measure data in accordance with NCQA and CMS technical specifications.
Maintains oversight of external data sources and vendors.
Use available Stars data to identify opportunities for improvement and support the development of Stars program initiatives.